Preventive oral health practices of school pupils in Southern Nigeria.

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(bmc

Oral Health

RESEARCH ARTICLE Open Access

Preventive oral health practices of school pupils
in Southern Nigeria

Morenike 0 Folayan 1 *, Mohammad R Khami 2+ , Nneka Onyejaka 3 , Bamidele 0 Popoola 4t
and Yewande Isabella Adeyemo 5+

Abstract

Background: One of the goals of the World Health Organisation goal is to ensure increased uptake of preventive
oral self-care by 2020. This would require the design public health programmes that will ensure children place
premium on preventive oral health care uptake. One effort in that direction is the need for countries to define
baseline measures on use of preventive oral self-care measures by their population as well as identify factors
that impact on its use. This study aims to determine the prevalence and the impact of age and sex on the use
of recommended oral self-care measures by pupils in Southern Nigeria.

Methods: Pupils age 8 to 16 years (N = 2,676) in two urban sites in Southern Nigeria completed a questionnaire
about recommended oral self-care (use of fluoridated toothpaste, flossing, regularity of consuming sugary
snacks between main meals), time of the last dental check-up and cigarette smoking habit. Chi square was used
to test association between age (8-10years, 11-16 years), sex, and use of recommended oral self-care. Logistic
regression analysis was used to determine the predictors of use of recommended oral self-care.

Results: Only 7.8% of the study population practiced the recommended oral self-care. Older adolescents had an
8.0% increased odds (OR: 1 .08; Cl:0.81 -1 .43; p = 0.61 ) and males had a 20.0% decreased odds (OR: 0.80; Cl:0.60-1 .06;
p = 0.1 2) of practicing recommended oral self-care though observed differences were not statistically significant. Very
few respondents (12.7%) had visited the dental clinic for a check-up in the last one year. Majority of the respondents
(92.2%) were non-smokers.

Conclusions: The use of a combination of oral self-care approaches was very low for this study population. Age and
sex were predictive factors for the use of components of the oral self-care measures but not significant predictors of
use of recommended oral self-care. Future studies would be required to understand 'why' and 'how' age and sex
impacts on the use of caries preventive oral self-care measures to be able to design effective prevention educational
programmes for the study population.

Background

The aetiology of most oral diseases are behaviour-related
[1-3]. These can be prevented by adopting and maintain-
ing healthy habits, ensuring oral self-care [3-5] and acces-
sing regular dental check-ups [6,7]. These same principles
are essential for caries control, a disease that is highly
prevalent in children in many parts of the world. Thus
where compliance with oral hygiene instruction and
healthy habits is poor, instituted caries control measures

* Correspondence: toyinukpong@yahoo.co.uk
+ Equal contributors

'Department of Child Dental Health, Obafemi Awolowo University, lle-lfe,
Nigeria

Full list of author information is available at the end of the article

may fail independent of the effectiveness of the preventive
method used [8].

Oral health habits of significant importance in caries pre-
vention in children include the use of fluoridated tooth-
pastes [9-12], twice daily brushing [13,14], the use of dental
floss for interdental cleaning, restriction in consumption of
refined carbohydrate in-between meals [15-17] and regular
dental checkups. In addition, there is the need to pay close
attention to prevention of tobacco smoking due to its det-
rimental effects on general and oral health [18,19], and the
incidence of oral cancers [20,21].

In Nigeria, though the prevalence of dental caries is
low, the rate of unmanaged dental caries is high result-
ing in significantly high risk for odontogenic infection

© 2014 Folayan et al.; licensee BioMed Central ttd. This is an Open Access article distributed under the terms of the Creative
BlOlVlGCl C^ntrBl Commons Attribution ticense (http://creativecommons.Org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly credited.

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[22,23]. Reasons for poor utilization of oral health care
services has more to do with an unperceived need for
these services due to the absence of pain. The risk of de-
veloping a spiral effect that results in significant increase
in caries prevalence and severity due to untreated dental
caries is high: children with untreated dental caries have
a five-fold increased risk of having a new lesion over a
three year period [24]. These same children may one day
become parents who could infect their children with
cariogenic organisms. While this hypothesis remains un-
tested, the feasibility of this makes it an imperative for
public health workers to place high premium on the in-
stitution of preventive oral health care in children in line
with the WHO goal of ensuring increased uptake of pre-
ventive oral self-care by 2020 [25]. It is therefore import-
ant to strategically design public health programmes that
will ensure children place premium on preventive oral
health care uptake.

A first effort in this direction will be to understand the
current preventive oral health care practices of children,
the level of influence of care givers and significant others,
and impact of proxy to dental care services in promoting
oral self-care of children. This study shall specifically focus
on determining the prevalence of use of recommended
oral self-care measures - a combination of prescribed
dental caries prevention measures - by primary and sec-
ondary school pupils in urban centres in Southern Nigeria
where dental care services is available; and the possible
impact of age and sex on the likelihood of using these oral
self-care measures.

Methods

Background information

This study was conducted in Nigeria, a highly populous
country with young persons and adolescents constituting
55% and 23% of its population respectively. Thirty mil-
lion children are in school [26] representing only 62.1%
and 44.1% of eligible primary and secondary school stu-
dents [27]. The country is made up of 36 states divided
into six geopolitical zones. Three of geopolitical zones
are in either of the two regions (Northern and Southern
Nigeria). The culture, norms, dietary habits, beliefs and
practices of the two regions differ significantly, though
there is more homogeneity within the regions. The num-
ber of decayed, missing and filled teeth (DMFT) are
higher in children from Northern Nigeria [28].

Study design

This is a cross sectional study enrolling a sample of pu-
pils in primary and secondary schools in two states in
Southern Nigeria: Ibadan and Enugu. The two states
were selected from the 18 states in Southern Nigeria
based on ease of access by the study team. The two

states represented the two major cultural groups in
southern Nigeria - Yorubas and Igbos.

In each state, pupils from primary and secondary
schools in the three local government areas that make
up Enugu metropolis and the five local government
areas that make up Ibadan metropolis were randomly se-
lected using a multi-prong approach.

The sample was first proportionally distributed amongst
the Local Government Areas and then, proportionately
distributed between the private and public schools in the
Local Government Areas. Each public and private second-
ary school from which participants emerged were selected
from the sampling frame based on a constant of K = 10
(The constant K was chosen to be 10 based on the least
number of schools in a local government such that every
10th school in each local government was selected for the
study).

In each school, the classes with the highest number of
pupils who met the age eligibility criteria were selected
for the study. Children who fall within the age range for
the study were recruited into the study. Recruitment in
each school continued till the sample size for the school
was reached.

Sample size

The minimum sample size calculated for the study was
1,333 for Enugu and 1,228 for Ibadan. The sample size
was calculated using a standard normal deviate at 95%
confidence interval, standard normal deviate of 1.96
when the beta error allowed is 10% and the power of the
study is 90%. The prevalence of caries of 15.0% in Enugu
[29] and 10.8% in Ibadan [30] was used for the sample
size estimation.

Target population

The study population consisted of children aged 8-16
years recruited from 34 primary schools and three sec-
ondary schools in Enugu metropolis, and 21 secondary
schools and three primary schools in Ibadan metropolis.
The minimum age for study participation was fixed at
age 8 years so as to ensure appropriate responses for
each of the items in the study questionnaire could be
generated. Informed consent for study participation was
sought from the parents of all the children. Assent was
also sought from children age 12 and above. Only chil-
dren who were willing to participate in the study were
recruited into the study. Pupils with special needs (phys-
ically, medically and mentally challenged) were excluded
for the study.

Questionnaire administration

The study adopted the questionnaire utilized by Khami
et al. [31] for the assessment of preventive oral self-care in
dental students. Questionnaires were self-administered

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and had fixed responses. A team of two researchers were
trained to administer the questionnaire in each of the
classrooms where students were recruited. The researchers
served as guide to the pupils and answered any clarifying
questions: they went through the questionnaire with the
class and gave expounded explanations for each of the six
questions and their options.

The questions asked for specific information on fre-
quency of tooth brushing, use of dental floss, consump-
tion of sugar-containing snacks or drinks between main
meals, smoking of cigarette, and time of last dental
check-up. Researchers provided specific guide on the use
of fluoride containing toothpaste by highlighting the
various types of fluoride and non-fluoride containing
toothpastes in the market. Where alternatives to tooth-
pastes were used for tooth cleansing, respondents were
asked to tick the option that reflected they do not use
fluoride containing toothpaste for tooth cleaning.

The purpose of the study and issues of confidentiality
were highlighted on each questionnaire. Instructions on
how to complete the questionnaires were also clearly
stated. Pupils were asked to refrain from recording their
names on the questionnaire for reasons of confidential-
ity. They were however asked to indicate their sex (male
or female) and age (at last birthday in years). The ques-
tionnaire requested information on respondents' oral
health behaviour. The questionnaire assessed:

1. Oral Self-Care: Recommended oral self-care was defined
as a composite score derived from indications of
brushing teeth at more than once a day, use of
fluoridated toothpaste, and consumption of sugary
snacks between main meals less frequently than
once a day [20,32,33]. Each respondent needs to
have met the three criteria to be categorised as
practicing recommended oral self-care

2. Tooth-brushing: Respondents were also asked to
indicate the frequency of tooth brushing using the
following alternatives - irregularly or never, Once a
week, a few (2-3) times a week; once a day, and
more than once a day. Respondents who chose the
options 'irregularly or never, Once a week, a jew (2-3)
times a week; once a day were classified as not having
undertaken preventive dental care.

3. Use of fluoridated toothpaste: Respondents were also
asked to indicate the frequency of use of fluoridated
toothpaste when tooth brushing using the following
alternatives - Always, quiet often, seldom, not at all.
Respondents who chose the options 'quiet often,
seldom, not at all were classified as not having
undertaken preventive dental care.

4. Consumption of sugary snacks between meals:
Respondents were also asked to indicate the
frequency of consuming sugar-containing snacks or

drinks between your main meals using the following
alternatives - About 3 times a day or more, about
twice a day, about once a day, Occasionally; not every
day, rarely or never eat between meals. Respondents
who chose the options About 3 times a day or more,
about twice a day, about once a day , were classified
as not having undertaken preventive dental care.

5. Use of dental floss: Respondents were also asked to
indicate how often dental floss was used for to clean
the teeth using the following alternatives - Not at
all, occasionally, a few {2-3} times a week, once in a
day, more than one time in a day. Respondents, who
chose the options 'Not at all, occasionally, a few
{2-3) times a week' , were classified as not having
undertaken preventive dental care.

6. Dental service utilization: Respondents were also
asked to indicate the time of the last check-up using
the following alternatives - within the last 6 months,
more than 6 months to one year ago, more than 1 to
2 years ago, more than 2 to 5 years ago, more than

5 years, never, do not remember. Attending a dental
check-up within the last year was defined as preventive
care use. Respondents who chose the options 'more
than 1 to 2 years ago, more than 2 to 5 years ago, more
than 5 years, never, do not remember were classified as
not having undertaken preventive dental care.

7. Smoking habits: The questionnaire requested
information on the respondents' habits of cigarette
smoking separately. The questions had six
alternatives - No, never, No, I used to, but I quit, Yes,
once a month or less, Yes, a few times (2-3) a month,
Yes, a few times (2-3) a week, Yes, once a day or
more. To dichotomise the variable, those who reported
no present smoking habits were considered as
non-smokers. All those who chose options 'Yes,
once a month or less, Yes, a few times (2-3) a
month, Yes, a few times (2-3) a week, Yes, once a
day or more were classified as smokers.

Statistical analysis

Chi-square test was used to test for significant differences
between subgroups. Binary logistic regression models were
fitted to the data to calculate odds ratios (OR) and confi-
dence intervals (95% CI) for each of the four oral self-care
measures. The independent variables for the model were
sex and age. Age was dichotomised using the median age
as the point of dichotomisation. The median age for the
study group was 11 years. Children 8-10 years were re-
ferred to as the younger age group while those 11 to 16
were referred to as the older age group. The binary logistic
regression model was used to calculate the association of
the independent variables with dependent variables (tooth
brushing more than once a day, intake of sugary snacks
less than once a day, regular use of fluoride toothpaste,

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and use of dental floss every day or more). Association be-
tween the independent variables and recommended oral
self-care was also assessed. STATA version 10 was used
for data processing and statistical analysis.

Ethical consideration

Approval was obtained from the Research and Ethics
Committee of University of Nigeria Teaching Hospital,
Enugu, and the University College Hospital, Ibadan. Per-
mission was also sought from the State Ministry of Edu-
cation via the Schools Management Board in the Local
Government Area, and the Head of the various schools.

Results

A total of 2,676 (1,223 males and 1,453 females) pupils
were recruited into the study. This represents 4.5% more
than the minimum sample size required for the study.
None of the students who met the eligibility criteria for
study participation refused to participate in the study.
The mean age for the group was 11.1 ± 2.39 yrs while
the median age for the group was 11 years. There were
1,211 and 1,465 pupils categorized as younger and older
age group respectively.

Most respondents (2,209 - 82.5%) reported frequent
use of fluoride containing toothpastes. More younger
than older pupils reported the use of fluoride containing
toothpaste (92.7% vs 74.1%; p < 0.001). Most of the re-
spondents (55.7%) reported once a day brushing with
only 31.5% of respondents brushing more than once a
day. There was no age group (p = 0.6) nor sex (p = 0.5)
differences observed for those who brushed more than
once a day. Less than a quarter of the respondents
(22.6%) had ever used the dental floss. More older than
younger respondents use the dental floss once a day or
more when compared (14.4% vs 3.5%; p < 0.001). Also
more older than younger respondents (34.7% vs 24.9%;
p < 0.001) and more females than males (34.4% vs 25.4%;
p < 0.001) ate sugar-containing snacks less than once a
day. See Table 1.

'Variables 1, 2 and 3 constituted the index "Practice of recommended self-care".

Overall, only 7.8% of the study population practiced
the recommended oral self-care: More older than youn-
ger pupils (8.1% vs 7.4%; p = <0.001) and more females
than males (8.6% vs 6.9%; p = 0.03) practiced the recom-
mended oral self-care (Table 1).

Very few respondents (12.7%) had visited the dental
clinic for a check-up in the last one year preceding the
survey. More older than younger respondents (16.3% vs
8.3%; p < 0.001) and more males than females (14.5% vs
11.1%; p = 0.007) had visited the clinic in the last one
year. Also, majority of the respondents (92.2%) were
non-smokers with more younger than older respondents
(99.2% vs 86.3%; p = <.001) being non-smokers.

Tables 2 and 3 shows a summary of the predictors of
preventive oral health practices by respondents. Older
adolescents had an 8.0% increased odds (aOR: 1.08;
CLO.81-1.43; p = 0.61) and males had a 20.0% decreased
odds (aOR: 0.80; CLO.60-1.06; p = 0.12) of practicing rec-
ommended oral self-care though observed differences
were not statistically significant. Older adolescents had
significantly increased odds of using flossing once a day
(aOR: 4.69; CL3.33 - 6.59; p < 0.001), taking in between
meals snacks less than once a day (aOR:1.57; CIrl.33 -
1.87; p < 0.001), vising the dentist at least once a year
(aOR:2.14; CL1.68-2.73; p < 0.001), and being a smoker
(aOR:21.01; CL10.72-41.17; p < 0.001); and a significant
decreased odds of using fluoridated toothpaste always
(aOR:0.22; CLO.18-0.29; p < 0.001) when compared to
younger adolescents. Also, males had a decreased odds
of taking in between meals snacks less than once a day
(aOR:0.66; CLO.55-0.78; p < 0.001) and an increased odds
of visiting the dentist at least once a year (aOR:1.44;
CL1.1 1-1.76 p = 0.004) when compared with females.

Discussion

This study was able to highlight that the use of fluoride
containing toothpaste was widespread among the study
population. However, the practice of twice daily tooth
brushing and the use of dental floss were low. Also, less

)

6)

)

Table 1 Number and percentage of school children who reported preventive oral health practices (N = 1863)

Variables: preventive oral health practices Age Sex

8-10 yrs 11-16 yrs P value Male Female P value Total

N = 1,211 N = 1,465 N = 1,224 N = 1,452 N = 2,676

1 Brushes more than once a day 394 (32.5%) 450(30.7%) 0.60 463 (37.8%) 481(33.1%) 0.15 844(31.5%

2 Use fluoridated toothpaste always or almost 1,123 (92.7%) 1,086(74.1%) 0.000 1,017(83.1%) 1,192 (82.1%) 0.50 2,209 (82.59
always

3 Eat sugar-containing snacks less than once a day 301(24.9%) 508 (34.7%) 0.000 311(25.4%) 499(344%) 0.000 809(30.2%
"Practice of recommended oral self-care 90(74%) 119(8.1%) 0.000 84(6.9%) 125(8.6%) 0.03 209(7.8%)

4 Floss at least once a day 42(3.5%) 211(14.4%) 0.000 113(9.2%) 140(9.6%) 0.72 253(9.5%)

5 Dental check-up within last 1 year 100(8.3%) 239 (16.3%) 0.000 178(14.5%) 161(11.1%) 0.007 339(12.7%

6 No present smoking habit 1,201(99.2%) 1,265(86.3%) 0.000 1,131(92.4%) 1,335 (91.9%) 0.61 2,466(92.2°/

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Table 2 Predictor for use of preventive oral health practices by age for school children in Southern Nigeria (N = 1863)

Age

8-1 0 yr (Ref. group) 1 1 -1 6 yr

Unadjusted
OR (CI)

., , Sex adjusted ,, ,

p-Value OR J (c|) p-Value

Brushing

Once a day or less 1832 (68.5%)

More than once a day 845 (31.5%)
Fluoride tooth paste

Not always 467 (17.4%)

Always 2210 (82.5%)
Snaking in between meals

Once a day and more 1866 (69.6%)

Less than once a day 81 1 (30.2%)
Practice of recommended oral self-care

Not perfect 2465 (92.2%)

Perfect 212 (7.8%)
Dental visit (Check-up)

Less than once a year 2331 (87.3%)

At least once a year 346 (12.7%)

Flossing

Less than once a day 2424 (90.5%)
At least once a day 253 (9.5%)

Smoking

Not Current smoker 2469 (92.2%)
Smoker 208 (7.8%)

817(674%) 1015(69.3%)

395 (32.6%) 450 (30.7%) 0.92 (0.78 - 1 .(

0.30 0.91 (0.77 -1.07) 0.27

88 (7.3%) 379 (25.9%)

1124(92.7%) 1086(74.1%) 0.22(0.18 - 0.28) <0.001 0.22(0.18-0.29) <0.001

909 (75.0%) 957 (65.3%)

303 (25.0%) 508 (34.7%) 1 .59 (1 .35 -1 .89) <0.001

1120 (92.4%) 1345(91.8%)

92 (7.6%) 1 20 (8.2%) 1 .09 (0.82 - 1 .44) 0.57

1.57 (1.33 -1.87) <0.001

1.08(0.81-1.43) 0.61

1108(91.4%) 1223 (83.5%)

1 04 (8.6%) 242 (1 6.5%) 2.1 1 (1 .65 - 2.69) <0.001 2.1 4 (1 .68 - 2.73) <0.001

1 1 70 (96.5%) 1 254 (85.6%)

42(3.5%) 211(14.4%) 4.69(3.33 - 6.59) <0.001 4.69(3.33 -6.59) <0.001

1203 (99.3%) 1266(86.4%)

9 (0.7%) 1 99 (1 3.6%) 21 .01 (1 0.72 - 41 .1 6 <0.001 21 .01 (1 0.72 - 41.17) <0.001

than a third of the respondents consumed sugar less
than once a day. These findings may most likely be a
true reflection of the status of oral health practices in
the population based on the strength of the method-
ology used in this study. First, the responses were an-
onymous which enhanced confidentiality. The issue of
confidentiality was also highlighted to the respondents
when the study was introduced by the researchers in the
field. Secondly, the students filled the questionnaire
themselves therefore reducing the changes of response
bias that may have resulted with an interviewer adminis-
tered questionnaire.

This study highlights some interesting findings. Com-
bination of approaches is important for successful be-
haviour dependent interventions [31] as is the case with
caries prevention [32]. The most important caries pre-
ventive oral health practice for children is a combination
of assured continuous use of fluoridated toothpaste once
a day or more [16], and restricted intake of refined
carbohydrate. Unfortunately, an extremely low number
of study respondents use a combination of these caries
prevention approaches.

The literature discusses extensively about the role of
individual factors for the prevention and control of car-
ies in children. Unfortunately, very little is known about

the efficacy and practices of a combination of these ap-
proaches in children. There have been prior studies on
combination approach for caries prevention in dental
students in Iran [32], Nigeria [33], and Mongolia [34],
and among dental educators in Mongolia [17]. The au-
thors could find no literature discussing the use of a
combination of preventive oral health care practices in
children. Although age and sex were not significant pre-
dictors of the use of recommended oral self-care, they
were significant predictors of use of some preventive
oral health care practices as enumerated in Tables 2 and
3. Older adolescents seem to have better preventive oral
health care practices (flossing, dental visits, snacking)
than younger adolescents.

Regular utilization of oral health centres is also a hall-
mark for preventive oral health care. Consistently, the
literatures show poor dental service utilization by chil-
dren in Nigeria [35,36], and high rates of untreated car-
ies with its attendant problems [23,24]. Regular dental
service utilization was low in this study indicating a need
to identify and institute actions that could facilitate ac-
cess of pupils to dental care. Males had had more annual
dental visits than females. The reasons for this is not
quite clear: visits may have resulted from the need for
curative treatment since they have greater risk for caries

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Table 3 Predictor for use of preventive oral health practices by sex for school children in Southern Nigeria (N = 1863)

Sex

Female (Ref. group) Male

Unadjusted
OR (CI)

p-Value A9e 0 R^ci) Sted P" Value

Brushing

Once a day or less 1832 (68.5%)
More than once a day 845 (31.5%)
Flouride tooth paste

Not always 467 (17.4%)
Always 2210 (82.5%)

Flossing

Less than once a day 2424 (90.5%)
At least once a day 253 (9.5%)

Practice of recommended oral self-care
Not perfect 2465 (92.2%)
Perfect 212 (7.8%)

Snaking in-between meals

Once a day and more 1866 (69.8%)
Less than once a day 81 1 (30.2%)

Dental visit (Check-up)

Less than once a year 2331 (87.3%)
At least once a year 346 (12.7%)

Smoking

Not Current smoker 2469 (92.2%)
Smoker 208 (7.8%)

972 (66.9%)
481 (33.1%)

260 (17.9%)
1193 (82.1%)

1313 (90.4%)
140(9.6%)

1327 (91.3%)
126(8.7%)

953 (65.6%)
500 (34.4%)

1288(88.6%)
165 (11.4%)

1337 (92.0%)
116(8.0%)

860 (70.3%)

364 (29.7%) 0.86 (0.73 - 1 .01 ) 0.06 0.85 (0.72 - 1 .00) 0.06
207 (16.9%)

1017(83.1%) 1.07 (0.88 -1.31) 0.51 1.02 (0.83 -1.26) 0.84
1111 (90.8%)

1 1 3 (9.2%) 0.95 (0.74 - 1 .24) 0.72 1 .00 (0.77 - 1 .30) 1 .00
1138 (93.0%)

86 (7.0%) 0.80 (0.60 - 1 .06) 0.1 2 0.80 (0.60 - 1 .06) 0.1 2
913 (74.6%)

31 1 (25.4%) 0.65 (0.55 - 0.77) <0.001 0.66 (0.55 - 0.78) <0.001

1043 (85.2%)

181 (1 4.8%) 1 .35 (1 .08 - 1 .70) 0.009

1.40(1.11-1.76) 0.004

1132 (92.5%)

92 (7.5%) 0.94 (0.70 - 1 .25) 0.65 1 .00 (0.75 - 1 .34) 0.9

*Age as a dichotomous variable (8-1 0 years vs. 11-16 years).

resulting from worse snacking habits when compared to
females. A prior study had shown that females had de-
ceased caries risk when compared to males [37].

Tobacco smoking is an important public health issue
having been implicated as a major risk factor for a range
of oral diseases like periodontal disease, leukoplakia, leu-
koedema and oral cancer. Many smokers start before the
age of 18 years [38]. This study showed that a larger pro-
portion of older than younger pupils smoke. The direc-
tion of this observation cannot be readily deciphered
from the results of this study (whether smoking in-
creases with age or whether smoking tendencies have
decreased with time). It is however important to under-
stand the direction of this observation so as to identify
necessary interventions if the association observed is an
increase in tendency to smoke with increasing age.

Understanding the implication of the findings from
this study may indeed inform design of public oral
health programmes targeting school pupils in Southern
Nigeria. The data seem to suggest that preventive oral
health habits are picked up in later years which may be
through other forms of socialization outside the home.
These teenagers may have learnt about appropriate oral
health care practices through the secondary socialization

process. It will be important to understand how pupils
learn about oral health care, and then effectively use of
these media to reach out to children and adolescents.
The reasons for and implications of the sex differences
observed with use of recommended oral self-care in this
study will need to be explored further using possibly
qualitative study methods. Prior studies in Nigeria had
shown that oral hygiene and oral hygiene practices are
better in females than males [39,40]. The explanation for
this observation remains unknown.

This study has its limitations. First is the inability to
generalize the outcome of this study to all children in
Southern Nigerian as a significant number of children
who are not in school and those not resident in urban
areas were not included the study sample. Secondly, data
was not captured on the possible role of the socio-
economic status of the child - a factor that would influ-
ence the ability to purchase many of the commodities
needed for preventive oral self-care - as a potential limit-
ing factor to the use of recommended self-care. Third,
the sample size for the study was generated using the
prevalence of caries - an outcome variable for the study -
rather than the prevalence of preventive self-care care
practice thereby introducing a type 1 error into the study.

Folayan et al. BMC Oral Health 2014, 14:83
http://www.biomedcentral.com/1472-6831/14/83

Page 7 of 8

Future studies on oral health issues in children in Nigeria
would better be conducted using a household survey to
ensure enrolment of both in and out of school children
and adolescents.

Conclusions

In conclusion, the use of recommended oral self-care
measures for caries prevention in this study population
was low due to low number of persons who brush twice
daily and the high number of persons who consume
sugar-containing snacks or drinks between main meals
daily or more. School based programmes can therefore
focus on addressing these factors. Age and sex were pre-
dictive factors for the use of components of the oral self-
care measures. Future studies would be required to
understand 'why' and 'how' age and sex impacts on the
use of caries preventive oral measures so as to be able to
design effective prevention programmes for the study
population.

Competing interests

The authors declare that they have no competing interest.
Authors' contributions

MOF: initiated the study, made substantial contributions to conception,
design, acquisition, analysis and interpretation of data for this study; has
been involved in drafting and revising the manuscript for important
intellectual content; and has given final approval of the version to be
published. MRK: made substantial contributions to design, and interpretation
of data for this study; has been involved in drafting and revising the
manuscript for important intellectual content; and has given final approval of
the version to be published. BOP: made contributions to design, acquisition,
analysis and interpretation of data for this study; has been involved in
drafting and revising the manuscript for important intellectual content; and
has given final approval of the version to be published. NO: made
substantial contributions to design, acquisition, analysis and interpretation of
data for this study; has been involved in drafting and revising the
manuscript for important intellectual content; and has given final approval of
the version to be published. YIA: made contributions to acquisition of data
for this study; has been involved in drafting and revising the manuscript for
important intellectual content; and has given final approval of the version to
be published.

Acknowledgement

We acknowledge the help provided by Dr AR Shamshiri with the statistical
analysis and review.

Author details

'Department of Child Dental Health, Obafemi Awolowo University, lle-ife,
Nigeria. 2 Research Center for Caries Prevention, Community Oral Health
Department, School of Dentistry, Tehran University of Medical Sciences,
Tehran, Iran, department of Child Dental Health, University of Nigeria
Teaching Hospital, Enugu, Nigeria. 4 Department of Child Oral Health,
University of Ibadan, Ibadan, Nigeria. 5 Department of Child Oral Health,
University College Hospital, Ibadan, Nigeria.

Received: 11 August 2013 Accepted: 7 April 2014
Published: 7 July 2014

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Cite this article as: Folayan et al: Preventive oral health practices of
school pupils in Southern Nigeria. BMC Oral Health 2014 14:83.

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